A nurse is caring for four clients. Which of the following clients is at the greatest risk for falling?

A client who has diminished vision ambulating in well-lit areas

A client who received a diuretic 30 min ago

A client who requires assistance with ambulation

A client who had a tonic-clonic seizure 2 hr ago

Answer and Explanation

The Correct Answer is D

A.   A client with diminished vision ambulating in well-lit areas may be at risk for falling but is not at the greatest risk among the options provided.
B.   A client who received a diuretic 30 min ago may experience orthostatic hypotension, which can increase the risk of falling, but it is not the highest risk.
C.   A client who requires assistance with ambulation is generally at a lower risk than a client who has recently experienced a tonic-clonic seizure.
D.   A client who had a tonic-clonic seizure 2 hr ago is at the greatest risk for falling due to potential residual weakness, disorientation, or postictal state following the seizure.

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Correct Answer is A

Explanation

A. Eating a light carbohydrate snack before bedtime can promote sleep by providing a small increase in insulin, which facilitates the entry of tryptophan into the brain, promoting the production of serotonin and melatonin.

B. Taking a 30-minute daily nap, especially close to bedtime, may interfere with nighttime sleep.
C. Exercising 1 hour before bedtime can be stimulating and may disrupt sleep patterns.
D. Drinking a cup of hot cocoa before bedtime may not be recommended as it contains caffeine, which can interfere with sleep.

A. Hold the dropper 1/2 inch (1 cm) above the ear canal during administration. B. Place a cotton ball into the inner ear canal for 30 min following administration. C. Straighten the ear canal by pulling the auricle down and back prior to administration. D. Apply pressure to the nasolacrimal duct following administration.

Correct Answer is A

Explanation

A. Holding the dropper 1/2 inch (1 cm) above the ear canal during administration (option A) is indeed the correct action when administering otic medications. This distance helps to ensure that the medication is properly instilled into the ear canal without touching the dropper tip to the skin or ear canal, reducing the risk of contamination.
B. Placing a cotton ball into the inner ear canal is not necessary following otic administration. It may cause unnecessary discomfort to the client.

C. Straightening the ear canal by pulling the auricle down and back can make the medication trickle out of the ear. It should be held outward and upward.
D. Applying pressure to the nasolacrimal duct is a technique used for ophthalmic medications, not otic medications.

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A nurse is caring for four clients. Which of the following clients is at the greatest risk for falling?

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